A list of the most recent deficiencies for Agility Health and Rehabilitation. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-11-21 | 2023-12-12 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2023-08-30 | 2023-09-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-30 | 2023-09-25 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-04-07 | 2023-05-01 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-04-07 | 2023-05-01 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-04-07 | 2023-05-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-07 | 2023-05-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-07 | 2023-05-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-04-07 | 2023-05-01 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-04-11 | 2023-05-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-04-11 | 2023-05-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-11 | 2023-05-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-11 | 2023-05-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-11 | 2023-05-01 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-04-11 | 2023-05-01 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-04-11 | 2023-05-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-11 | 2023-05-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-04-11 | 2023-05-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-04-11 | 2023-05-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-11 | 2023-05-01 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-04-11 | 2023-05-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-04-11 | 2023-05-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-11 | 2023-05-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-14 | 2022-07-08 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-06-14 | 2022-07-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-23 | 2022-04-25 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-11-16 | 2021-12-17 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-11-16 | 2021-12-17 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-11-16 | 2021-12-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-16 | 2021-12-17 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-11-16 | 2021-12-17 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-11-16 | 2021-12-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-16 | 2021-12-17 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-11-16 | 2021-12-17 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-11-16 | 2021-12-17 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-11-16 | 2021-12-17 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-11-16 | 2021-12-17 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-11-08 | 2021-12-14 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-11-08 | 2021-12-14 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-11-08 | 2021-12-14 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-11-08 | 2021-12-14 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-11-08 | 2021-12-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-11-08 | 2021-12-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-11-08 | 2021-12-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-08 | 2021-12-14 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-11-08 | 2021-12-14 | N |
| Ensure that HVAC heat units are suspended and out of the reach of patients and can be shut off if unit is working improperly. | Fire Safety | 2021-11-08 | 2021-12-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-11-08 | 2021-12-14 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-11-08 | 2021-12-14 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-11-08 | 2021-12-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-11-08 | 2021-12-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-05-11 | 2021-06-23 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-05-11 | 2021-06-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-05-11 | 2021-06-15 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-05-11 | 2021-06-15 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2021-05-11 | 2021-06-15 | N |
| Install proper backup exit lighting. | Fire Safety | 2021-05-11 | 2021-06-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-05-11 | 2021-06-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-05-11 | 2021-06-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-05-11 | 2021-06-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-05-11 | 2021-06-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-11 | 2021-06-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-05-11 | 2021-06-15 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2021-05-11 | 2021-06-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-05-11 | 2021-06-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-05-11 | 2021-06-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-05-11 | 2021-06-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-05-11 | 2021-06-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-05-11 | 2021-06-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-05-11 | 2021-06-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-05-11 | 2021-06-15 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2021-05-11 | 2021-06-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-05-11 | 2021-06-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-12 | 2021-06-07 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-05-12 | 2021-06-07 | N |
| Post nurse staffing information every day. | Health | 2021-05-12 | 2021-06-07 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-05-12 | 2021-06-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-12 | 2021-06-07 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-03-18 | 2021-04-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-18 | 2021-04-16 | Y |
